Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.

Wednesday, August 09, 2006

Memorable patients: part five

Sturdy and thickly-built, long since widowed, cheery in a sardonic sort of way, tough and opinionated, Flora's European roots ran deep; she'd been an Italian farm girl, and she'd rather be in her garden than anywhere else. The only reason she agreed to come inside and go to the doctor was that her bowel movements had finally gotten too painful, and too bloody to ignore. Which she had been doing, for quite some time. Still, she made it clear seeing me was pretty low on her list of things she'd like to do. I liked her right off the bat: she said exactly what was on her mind, she treated me with no deference, but with an expectation of straight talk right back at her.

Wishing not to turn away readers, suffice it to say everything that was visible and feelable about her anus had been taken over by an angry, florid and unprecedentedly (in my experience) large cancer. She wasn't surprised when I told her what I thought was going on; she wasn't happy with what I told her would be needed to take care of it.

There are two main types of ano-rectal cancer: squamous cell cancer derives from the skin cells at the anal opening, while adenocarcinoma arises within the lining of the bowel itself. In some cases, the former can be treated by radiation alone, which --although not free of side effects -- is a generally nice thing for the patient. With adenocarcinoma, surgery is mandatory, with or without accompanying radiation and/or chemotherapy. In Flora's case, it almost didn't matter which kind it was, in terms of surgical decision: as large as it was, surgery was going to be needed at some point. It was easy enough to biopsy it: I just pinched off a clump with my fingers and sent it to the lab. Meanwhile, I told her about colostomy.

In the majority of cases of cancer involving the colon, surgery can easily be done, and it typically involves removing the segment of bowel containing the tumor and sewing the ends back together; effect on bowel function is generally zero. Most people can have normal bowel movements even if over half the colon is removed; for the typical cancer operation, way less than that is taken. But after you've removed the cancerous part along with enough healthy bowel to assure complete removal, you need something downstream to sew to. When the cancer is in the anorectum, ain't nothing left but the outside world.

The operation is called abdominoperineal resection, and it's a pretty big deal. You must divide the colon somewhere above the pelvic portion, then follow and free up the distal segment all the way through the pelvis, down to the deepest part. And at some point, with the patient's legs up in stirrups, you cut an ellipse of skin around the anal opening and work back up to the pelvic part of the dissection. If tidiness is desirable in surgery, this is the antithesis. Working deep into the pelvis is physically hard: the bony hole through which you are working is unforgiving. I may be suited for surgery in other ways, but my hands are too damn big. In the pelvis, they cramp up. And direct visualization is difficult.

Much of the work is done by feel, and using long instruments, the ends of which are sometimes out of view. Running along the sacrum is a plexus of fat veins which, because they adhere to the bone like a starfish on a rock, are extremely dangerous if they get to bleeding: you can't encircle them with suture without the risk of causing more bleeding. But we didn't get into all that yet. The main message is that the end of the colon comes out to the skin, permanently. Colostomy. And her case, it was going to be essential to have radiation and chemotherapy ahead of time. Healing of the perineum after AP resection is a worry under the best of circumstances. In a heavy lady, radiated before surgery, it was pretty much a guaranteed problem.

Flora was not happy. Her anger was intense but polite and controlled. "Doctor," she said. "I'm going to die sooner or later, and it's not going to be with a bag full of shit on my belly and a hole in my ass." She started assembling her belongings and aiming toward the door. "Mrs. So-and-so, " I said. "I know this is a lousy deal. But let's talk about it and think about it some more. Believe it or not, a colostomy isn't is bad as people think. You can do anything you want to do, and it won't interfere. I promise." There's a lot we talked about, and it took more than one session; I actually looked forward to our meetings. They were testy but clear-headed and eye to eye.

Our mutual respect grew with each encounter; at some level it felt like a game, the outcome of which was predetermined but which needed full playing out -- assurance that each party knew the rules. Eventually she agreed to see the radiation and medical oncologists. I also arranged a visit with the colostomy nurse (enterostomal therapist). Our hospital had a really good one: she had an ostomy herself.

With cajoling and commiserating, she ultimately went for it. I saw her a few times during her pre-op treatments; she'd grouse about this and that, complain that no one but me listened to her, sighed and swore. But she kept on keeping on. And that enormous and ugly tumor, which I've studiously refrained from describing in vivid detail, regressed very impressively. So we scheduled surgery, after giving some time for the reaction to simmer down. (The dose of pre-op radiation is less than if it were given postop; and combining it with chemo has an additive effect, so you may see quite good shrinkage with a relatively small dose.)

Nothing, evidently, kept Flora from her enjoyment of food. She was no tinier when I operated than when I first met her. Getting a colostomy out though a thick abdominal wall isn't easy. Fat in the pelvis makes the work no less tough, either. This happens to be one of the very few operations for which I order blood to be available. One and only one time in my career did I get into those veins, and it was a very close thing. In fact, I did something sort of unheard of: rather than trying to suture the veins and tear them further, I had the nurses scrounge some thumbtacks, (note the date of the article -- I did this ten years earlier) cook them in the sterilizer; after which I threaded them through clot-promoting material like peppers on a shishkebab, and poked them through the veins into the sacral bone. Worked amazingly well. I say that to impress you: it didn't happen to be Flora.

You just couldn't keep Flora down. She wanted up. She wanted out of there. She walked and coughed and cooperated and did everything necessary to make a quick exit from the hospital; and she did just that. Like most patients, she made peace with her colostomy, figured out how to irrigate it (give an enema through the opening) so it emptied when she told it to, damn it. And went back to gardening in very short order. When she came in for visits, she'd bring a bag of green beans, or peas. Sometimes a perfect tomato (better than the best, Dr Charles). Always with a complaint about something, never letting whatever it was keep her from doing what she wanted.

Long past the time I usually followed routine cancer patients (I figure they had plenty of docs and appointments, and made followup optional, after a time), she kept coming, year after year, at least once. She'd call and complain about life to my nurse; she'd ask for a call from me. And she'd always come in, too. I'd poke at her perineum, check her colostomy, feel her belly, get a couple of blood tests, and tell her she looked good for another year. Listen to her gripes, accept her bag of veggies.

Maybe five years later, Flora told me she was having trouble working in her garden. Her hip hurt too damn much. Damned if there wasn't a single metastatic nodule in her pelvis. An orthopedist carved it out (I had to convince him it made sense -- that he wasn't administering futile care), filled the hole with glue and a prosthetic cup; she had more chemo and radiation and went about her business. Kept coming in year after year, bearing veggies and gripes. A woman of the soil.

To which she eventually returned, a few years after that. My nurse missed her calls, and I missed her stolid presence, grousing about this and that, always with just enough of a smile to let you know she loved her life.

I learn something new everyday. I had no idea that a colostomy nurse was even an option. Anyways, I can so relate to this pt. I often wonder if her grit kept her going as long as it did.Thumbtacks? Really? They were permanent? I bet the medical transcriptionist had to rewind that tape a few times before putting it in print.

Hospitals that provide enterostomal therapy do a great service. It's really nice to be able to send a patient for a visit pre op; it helps enormously with the adjustment. And they find the perfect place on a given patient's body to place the stoma, marking it preop. Plus, they tend to also be experts in wound management.

Yep Thumbtacks. You can actually get them now in "surgical grade" which, far as I can tell, are just the same as a non-painted one you could get for pennies; but these costs big bucks.

Thank you for the reflection...as a third year medical student, I got to scrub in on an APR, ( I am now a fourth year ) , and it is one of the many experiences that has shown me that I am supposed to be a surgeon.

On an outing to Border's today I got a peek at your book. I can't wait for payday :)

I've had the privilege of meeting women like her, though I wish I got to interact with patients to the length you do. Unfortunately bone scans are four hours start-to-finish, but they're only with us for about 30 minutes, most of which I'm out of the room.

Excellent story as usual; patients like these are gold. My surgeon mentor/friend had a book on his shelf on anorectal surgery. It was probably 3" thick. I thought the book itself was freaky, much less its heft. How much my world has widened since I started med school...

Oh yes, there was lots of laparoscopy. I took the courses and did the operations. I think it's very cool, and, despite no prior Nintendo experience, I found I was good at it and enjoyed doing something so new. The technology has progressed impressively. I work only with laparoscopy now, as an assistant. Before laparoscopy, I'd developed my own technique of cholecystectomy wherein I could do it through a one or one and a half inch incision in twenty minutes. I was never convinced (in fact, studies agree with me) that lap chole is better; the results are the same, and the costs of lap chole are thousands higher. Same with a properly done appendectomy. But there are some operations that are far superior done laparoscopically: fundoplication, obesity surgery, many splenectomies. Maybe it's fodder for another post. My little tirade...

My dad, who's a urologist, has brought home several fruits, veggies, and desserts from various patients over the years...........

One patient was a Greek guy who made the most delicious dessert things. This was easily between 7-10 years ago........I think he had a shoe store or something like that.

I suppose these patients more than make up for the occasional grouches who just won't be pleased no matter what, or ask you ten million questions (not for curiosity like I do, but to test you......like they don't trust your medical judgement or something) or patients who are so nervous they call you ten times after office hours (my dad had one of those......he called one time at dinner..........my dad went ballistic on him. I was shocked and embarrassed....and not too thrilled about Dad assaulting my sensitive auditory whatchamacallit........I'm autistic, I have sensitive hearing/vision/touch..........I have a very wide variety of a diet though.

About Me

Boring, Unoriginal, but Important Disclaimer:

What I say here is as true as I can make it, based on my experience as a surgeon. Still, in no way is it intended as specific medical advice for any condition. For that, you need to consult your own doctors, who actually know you. I hope you'll find things of interest and amusement here; maybe useful information. But please, please, PLEASE understand: this blog ought not be used in any way to provide the reader with ideas about diagnosis or treatment of any symptoms or disease. Also, as you'd expect, when I describe patients, I've changed many personal details: age, sex, occupation -- enough to make them into no one you might actually know. Thanks, and enjoy the blog.